Genetic Testing for breast cancer in India has been limited so far by the high cost of patented tests, need to ship samples overseas and social stigma towards genetic disease. However recent emergence of new technology such as next generation sequencing and local presence of genetic labs has brought down costs considerably. Hollywood actress Angelina Jolie’s story in the media brought a lot of public interest and debate to the topic. Patient interest in the topic is higher than it has been. The question is are we as doctor ready to hold this dialogue in our clinic?

What do we need to know about genes and mutations?

Everyone is born with two copies of approximately 25000 genes that are present in all nucleated cells of the body. One copy is inherited from each parent. Everytime a cell divides this large volume of genetic information is copied into the daughter cells. This process is prone to errors which lead to DNA damage or mutations. Cancerous cells are often cells that have accumulated several such mutations over a period of time and have acquired the ability to grow and spread uncontrollably. In this respect all cancers are “genetic” however not all cancers are “ hereditary”

Is breast cancer hereditary?

Only 5-10 percent of breast cancers can be attributed to known genetic mutations. Upto 20 percent cases may be familial even if no mutations are known or found. Most patients of breast cancer have no family history of the disease and children of most patients will not develop the disease i.e. these are sporadic cases.

What are the types of Genetic Testing in Breast Cancer?

There’s two broad categories of genetic tests we use in breast cancer.

Germline Testing : Germline DNA Analysis studies a person’s genetic make-up by testing DNA that is common to all cells in the body. Saliva swabs and blood are commonly used for this type of testing.

Somatic Testing or Tumor DNA testing: This is performed on the patient’s tumor sample for prognostic testing (eg Oncotype Dx) or pharmacogenetic testing for targeted therapies against the tumor.

1)Genetic Counseling: Genetic counseling is an imperative step prior to genetic testing. The session usually takes an hour or more and may need several sessions.

A genetic counselor obtains the relevant clinical history, plots a pedigree chart, obtains a detailed history of cancers, verifies pathology reports, physical measurements may be taken when needed. A computer model may be used to predict possibility of a hereditary breast ovarian cancer syndrome (BRCA 1/ BRCA 2) or other syndrome such as Cowden (PTEN) or Li Fraumini (p53).

Benefits and risks of testing are discussed. The possibility of a positive, negative or inconclusive result and their implications are discussed. The appropriate family member to be tested is identified and brought into the picture as needed.

After assessing the need for testing, the patient is given a choice to proceed with testing. Testing should be undertaken only after formal genetic counseling and informed consent.

2)Genetic Testing: The actual test involves collection of the patients blood/saliva sample. The genetics lab isolates the DNA and sequences part of the exome to look for a single or multiple mutations. Different techniques such as Sanger, NGS are used for this. The raw data needs extensive analysis with a reference database or repository to determine which of the mutations found are clinically relevant. A report is then generated which may describe absence or presence of certain mutations, that may be know pathogenic, known benign or have uncertain significance.

3)Post Test Counseling: This should be undertaken with an oncologist familiar with breast cancer genetics, who can guide the patient on interpretation of the test. If a known deleterious mutation in BRCA is found, options of prophylactic surgery versus heightened surveillance or pharmacological interventions should be discussed.

What is the cost of Genetic testing?

With use of Next Generation Sequencing, the cost of testing has lowered considerably. The additional cost of looking at multiple mutations is low, and once a familial mutation is known, other family members can be tested at much lower cost.

How long does genetic testing take?

The turnaround time from sample collection is usually 4-6 weeks. Depending on the data obtained, the time to analysis and interpretation may vary.

What are the limitations of Genetic testing in India?

*Most criteria used to predict risk of genetic mutations are written for western populations and the true prevalence for most Indian breast cancer patients is unknown.

*Social stigma in a world of arranged marriages, illiteracy; fear of social discrimination and misunderstanding of the disease or process may limit patients from using this information for making positive healthcare decisions.

* With high costs of oncological treatments, the additional expense of genetic testing, limits its availability to only a few of patients that may be eligible for it.

Who should be offered genetic testing?

Genetic “counseling” can be offered to any breast cancer patient or family member wanting to discuss this. Decision to perform “testing” should only be conducted after assessing need and implications of the test in a patient who is willing to use this information positively in their care.

Risk of breast cancer can be inherited from the maternal and paternal side and a pedigree chart should collect information on all of these relatives.

What does a “ positive” test result imply?

A patient with a known deleterious mutation in BRCA may have a 60-80% lifetime risk of developing breast and 40-60 % risk of developing ovarian cancer. In a patient with known breast cancer, the risk of developing a contralateral breast cancer may be as high as 40%.

What are the options for a BRCA positive patient?

Risk reducing surgery : This includes bilateral salpingo-oopherectomy after completion of child bearing and bilateral prophylactic mastectomy are proven to decrease risk of ovarian and breast cancer in over 90% . Bilateral mastectomy when performed using nipple-skin sparing technique and immediate reconstruction may not be as mutilating a procedure as it once was thought.

Pharmaco-prophylaxis: Use of medications such as Tamoxifen should be discussed. These can potentially lower risk (but not completely prevent cancers) in these patients.

What does a “positive” result mean to the patients children?

Every child has a 50% probability of inheriting an autosomal dominant mutation. They should be offered genetic testing once they are of age to given consent and understand implications of testing for themselves. If a child tests negative for the mutation known in the parent, their risk of breast cancer is the same as the average population. If the child has inherited the mutation, then similar counseling and decision-making should be offered as above.

1) Prognostic testing: One such assay Oncotype Dx gives a 21-gene recurrence score that predicts a patients risk of recurrence at 10 years. Small node negative breast tumors (T1-2, N0) that are ER+PR+ HER2 – can be stratified by their genetic makeup into low, intermediate and high risk. There is evidence that endocrine therapy alone may be sufficient for patients in the low risk category and adjuvant chemotherapy may be avoided.

2) Predictive Pharmaco-genetic testing: Tumor DNA is analysed to determine benefit from targeted therapies. ERBB2 (HER2/neu) gene amplification testing using FISH is widely used test for the decision to use anti-Her2 agents like trastuzumab. There is interest in developing “Personalized oncology’ treatments where genetic make up of the individual’s tumor would be used to select appropriate targeted therapies. This is an area of ongoing research. I discourage patients from using commercially available tests without guidance of an oncologist at this time.

What are circulating tumor cells and circulating tumor DNA?

CTCs are cells shed from the tumor that can be detected and measured in the patient’s blood. This is an area of intense research, which holds promise for early detection of recurrence, assessment of response to therapy, identification of targeted therapies etc. The optimal isolation techniques and definite guidelines for clinical use in breast oncology are still awaited.

]]>https://punebreastcare.wordpress.com/2017/02/21/genetic-testing-in-the-breast-clinic/feed/0drpranjaliscreen-shot-2017-02-21-at-8-25-13-pmslide13Breast Cancer Treatments Simplified..(Well Almost… )https://punebreastcare.wordpress.com/2017/02/21/breast-cancer-treatments-simplified-well-almost/
https://punebreastcare.wordpress.com/2017/02/21/breast-cancer-treatments-simplified-well-almost/#respondTue, 21 Feb 2017 14:37:19 +0000http://punebreastcare.wordpress.com/?p=1119Continue reading Breast Cancer Treatments Simplified..(Well Almost… )]]>The intense fear we have about cancer relates not only to the deadliness of the disease but the overwhelming nature of treatments involved. Time-and-again cancer proves that it certainly is a worthy enemy. Rationally then, we must use the most effective and powerful defenses available in medicine to fight it.

The treatments we have to fight breast cancer have three broad categories- 1) Surgery 2) Radiation and 3) Medical therapy which includes chemotherapy, endocrine therapy and biologic treatments.

Given that each breast cancer is unique, not each of these treatments is needed in every case. A surgical oncologist, breast surgeon or general surgeon usually does the surgery; the radiation oncologist plans the radiation; and the medical oncologist administers the medical therapies such as chemotherapy. In the course of treatment, the patient often has to go from one specialist to the other. This can often be a haphazard process that causes considerable confusion and anxiety. It is helpful to find a specialist that can outline a complete treatment plan from the beginning. (Fig) Clear expectations and plans allow patients to better plan their life and finances around treatments from the beginning. Breast cancer treatments have evolved considerably to be more effective and less invasive.

On the surgery front, removal of the breast i.e. a mastectomy need not be the disfiguring operation it is often feared to be. In a nipple and/or skin-sparing mastectomy, the entire skin envelope of the breast can be preserved and the breast replaced with an implant or a patient’s own tissue or flap. The reconstruction can often be performed at the same time as the cancer operation, which improves cosmetic outcomes. When the cancer is small enough, the patient can undergo a lumpectomy i.e. removal only of the part of the breast bearing the tumor. When combined with radiation, it allows the breast to be preserved (breast conservation therapy) and is as effective as mastectomy in treating the cancer. Lumpectomy is now being performed with oncoloplastic techniques that preserve aesthetic appearance of the breast. If the tumor is too large for lumpectomy, chemotherapy can be used before surgery to decrease its size. Surgery for the lymph nodes under the armpit is also part of the breast cancer operation. When feasible, this is minimized and only a few lymph nodes are sampled (sentinel node biopsy). The remaining nodes are only removed when the sampled sentinel nodes are found to have cancer. Side effects like arm swelling or lymphedema can thus be minimized.

On the medical therapy front, we increasingly have “smart treatments” that are customized to attack the specific tumor type. The medications used in breast cancer chemotherapy have become more effective over the years and there are better treatments for expected side effects such as nausea and vomiting. When chemotherapy is given through a ‘port’ implanted under the skin, discomfort of repeated IV sticks is avoided. Hair-loss from chemotherapy is still common, but almost always temporary. Not everybody with breast cancer may need chemotherapy and some tumors may be adequately treated with an oral anti-estrogen pill. This treatment called endocrine therapy is usually well tolerated and may be prescribed for 5 or more years.

On the radiation front, treatments have gotten more precise and safe. Unwanted radiation to organs such as heart and lungs is minimized during treatment of the breast. In selected cases after a lumpectomy, shorter treatment courses (1 week instead of the standard 5-6 weeks) can be used. Radiation is a painless treatment and when it targets the breast, it should not cause nausea vomiting or other such problems. The most common side effects pertain to irritation of the radiated skin and will improve after treatment is completed. Some patients that undergo a mastectomy for an early cancer, may avoid radiation altogether.

Survivorship issues after cancer treatments are not discussed as much as they ought to be. Completing cancer treatments is an arduous task and treatment completion does bring quite a relief. However most patients will tell you however that life after cancer is different and the change is real. Certainly acceptance of this change is a better strategy than denial, but several challenges prevent patients from returning to a “normal” life. Whether it is a change of self image, fear of recurrence or lingering side effects of treatment, it is better for patients to talk about their concerns than not. It helps to talk to the doctors about the new normal. It is important to know which of the lingering symptoms can be treated, which ones will improve over time and which ones the patient will eventually learn to live with. Patients will also worry about recurrence, but the truth is that worrying about recurrence doesn’t prevent it. I often tell patients that if you’re amongst the women that won’t ever have a recurrence, you’ve wasted precious life years worrying for nothing. If you are amongst the unfortunate ones that will, again you’ve wasted precious time worrying that you could have spent living. Its good to know that there are still treatment options for recurrences.

Remember that we fight cancer not because it’s an enemy worth fighting, but because life is worth living. If a patient can get back to living the joyous life she deserves, as long as it may be, to me she’s a winner.

Depression sucks. We’ve heard the reasons it exists and we often know our own. Bad genes, life stressors, neurotransmitter imbalance ..whatever. You just want to get better already! The self-help you read on exercise therapy, mindfulness or eating healthy, points out how you’ve been doing it all wrong. The friends who have it all together and ask you to “snap out of it” “think positive” or “jump on a treadmill” just don’t get it. Antidepressants, (if they don’t make you worse) may not always make you feel better. You could spend hours in psychotherapy hoping to understand why me? Bottom line is its hard to make sense of the depressed mind, let alone treat it.

On the other hand, we’re relatively lucid when we discuss the character of cancer. Despite the gaps in the science, we largely know how to think about it. Cancer cells are misbehaving cells that multiply uncontrolled. They try to replace our normal cells & disrupt the function of our organs. The immune system fails to fight flaws in our own cells and the mayhem goes uninterrupted. When we do get diagnosed, we learn that the cancer can often be removed, or the cells killed with chemo or radiation therapies. Often some normal tissue may have to be sacrificed to remove the cancer in its entirety -we more or less come to terms with that. Some of us at advanced stages of disease, can’t get rid of the cancer and must continue on therapies that keep cancer cells under control. At the back of all this, we’re very aware that the cancer although coming from my cells, is still “not me”.

What if you could think about depression like you think about cancer? We can certainly draw parallels in the character of the two diseases. Depressive thoughts are to the mind, as cancer cells are to the body. Negative thoughts try to replace more desirable ones. The repetitive , rumination of negative thoughts spirals out of control much like cell division in cancer. Self-worth and self-esteem fail in the presence of negativity, much like organs fail to cancer. Ya ok, you see there’s something there.

Could we take some lessons from cancer then and apply them to understanding depression and forming some style of coping with it?

Yes your “own” thoughts could be wrong: We are conditioned to trust our own thoughts. If my own mind says “I’m doomed” or “I’m worthless” or “this life isn’t worth living” then it must be true ! Challenge yourself to think for a moment that your brain could be sending you a bad message, a wrong signal or a “cancerous” thought. Yes it’s in your mind, but this thought or feeling may not be truly reflective of what is you! The thought that may not be doing you good, may have to be interrupted and let go.

You can’t fight it, if you deny it: Much like cancer or any other illness, you can’t treat depression without first acknowledging that you have it. Acknowledgement isn’t about saying “I should be happy, I hate to feel sad, I don’t want to be depressed!” A better example of acknowledgement is,” I understand someone else can be happy and positive in circumstances lot worse than mine- they perhaps don’t have the condition I have. I suffer from depression and I am trying to feel better”

Be kind to yourself: Largely, people find it easy to sympathize with cancer. They don’t sympathize as much with depression, because “It’s not like you’re dying or anything- you’re just feeling blue.” Your social withdrawal and inability to do enough for your relationships is certainly not helping. ‘You’ however know what you’re going through, so why not start with being kind to yourself and do it urgently and generously?

Respect your limitations: Someone on chemotherapy certainly wouldn’t go swimming in murky waters, knowing they could catch an infection. I’m not saying you should avoid all things challenging, just know that you will face more hurdles getting there than someone who doesn’t have your limitation, namely depression. A bungee jump to a different career or a new continent at 40 may be exciting for a friend or even for to the more optimistic version of yourself. It could however present a real risk of recurrence for someone living with depression. Choose your circumstances wisely when you can.

Living with it may be a more realistic goal than curing it. We all want to not have cancer, certainly not stage IV cancer. While I certainly don’t want to discount the struggles of those facing metastatic cancer, there’s a comparison to be made with depression in the need to ‘live with’ the condition you’re facing. Seeing yourself as living with well-controlled depression is perhaps more realistic than imagining it’s gone. You certainly don’t want to, but you know you may have to face it again. Try and find ways to help minimize your symptoms. Surround yourself with supporting friends and family and make the most of life’s better moments.

It may take giving up some of the good, to get rid of the bad. I make the most important point last. It may be hard to believe, but the same thinking habits that fuel your depression can be the ones that make you largely successful and may be the very traits you love about yourself. Let’s consider your need to excel, hold yourself to a high standard and deliver beyond what’s expected. It makes you the successful professional you are. An unexpected setback may have shatter this perfectionist self image. You’ve believed “I’m nothing if not perfect” and with the perfection tainted, your depressed self thinks “I’m nothing”. Consider next your ability to sit and mull over a problem, looking at it from multiple viewpoints for long hours. It makes you the great problem solver you are. When you’re depressed, there you are doing the same ruminating and repetitive thinking that now gets you nowhere. The reason we can’t nip the negative thoughts in our minds, is because deep down they may be rooted in very constant and positive aspects of our personalities; that which makes you “you”. Just as cancer surgery may involve getting rid of some good tissue with the bad, you may have to change or police these very habits that have served you well. You may not go from being a seriously disciplined to a carefree soul overnight, but you may question the merit of being harsh and disciplined if it only makes you depressed.

Its October and like every year, there’s going to be a lot of talk about breast cancer. It’s likely that each of you will come across something pink- a fundraiser walk, an awareness talk or at-least someone wearing a pink ribbon. When you do, be careful not to make these common wrong assumptions.

PInktober Mistake 1: ” It’s not for me”

Quote from a patient who presented with an advanced cancer: ” We organized an awareness and screening camp for our women’s’ group, but I didn’t think I needed it” Everyone assumes breast cancer is something that happens to someone else, but the truth is it can happen to anyone.

Pinktober Mistake 2: “Its probably nothing serious”

When someone finds an abnormality on a free mammogram, women assume it can’t be cancer because they “feel alright.” The whole idea is to find cancers before they have a chance to make you sick. Although most things we pick up are not cancers, make sure you undergo a complete diagnosis for whatever is found.

Pinktober Mistake 3: “I’ll get to it at some point”

Often women are participating in these drives and camps in the spirit of a “fun group activity” This is a different mindset from a woman who goes in all seriousness for a doctor visit. When what was supposed to be “just a pinktober event” reveals something important that needs attention, women procrastinate taking the next step.

Pinktober Mistake 4: Misreading the message altogether

The message of breast cancer awareness is read very differently by different women. Someone hears” There’s something called breast cancer, it happens to some women”. Another hears ” Oh my god, I’m scared now that I will get it” The actionable part of the message received should be: ” To lower my breast cancer risk, I’m going to start exercising” ” If I were to get it, I’d rather its detected early and therefore I’ll go for annual breast exams with a doctor; and mammograms as advised.”

Pinktober Mistake 5: Forget everything after October

Much like new year resolutions, women forget about the resolutions made in October a few months later. There’s a lot to do once October is over. If you’re over 40, note the last date of your mammogram and get the next one at a year from that date. Keep monthly self breast exams incorporated into your routine as “good habits.” Stay willing to discuss the topic with friends and family you meet. Lend a helping hand to someone who will deal with breast cancer this year.

As an oncologist however I have to hold myself back and say it like I see it…attempt to predict what is likely, and present the truth ..or the best that I know of it.

Sometimes reality is promising “You had a very small and early tumor, I’d be surprised if it came back” Sometimes reality is harsh “Your tumor is smarter than us, it keeps coming back but we have a few options that will get us more time”

More often that not, reality is in between. A statistic like “Out of 100 patients with your kind of tumor and treatments..73 will be alive in 10 years” Some patients can appreciate that information, but numbers are still numbers. The same number can be read differently by eyes that see either hope or fear. Besides, someone may think “I’m either doing to be alive or I’m going to be dead..and if I’m dead I’m completely a 100% dead, aren’t I?” Well..I hear you.

Once you have been through the cancer journey, my hope is that you will find a place where you are neither “fearful” nor “reckless”. Where you don’t see ” all black” or “all white” but find a way to be “okay with grey” Where you are informed and aware and peace with what you know and believe. A place where hope is something you feel grounded in, not something you are constantly searching and struggling to find.

So here are some sincere answers to your difficult question.

“Neither of us knows for sure whether it will come back or not.. we have all done everything in our ability to prevent it from coming back …lets give ourselves permission to sit back a while and trust that our efforts will pay off”

” If most women in your situation will not have a problem , then going forward I want you to believe you are in this group that is cured. I am also here for those that will find that they are not..and we will face it together again if we must”

“The goal of getting through cancer treatments is to get you back to living your life.. you are there today. now lets see you live.. “

Yes, every now and then you will wonder whether you will be ok. Cancer support slogans will exhort you to “stay positive” “keep fighting” and drive you to believe that you win if you will be ok and stay ok. In my opinion thats a hurtful agenda during survivorship and makes it harder than it should be. The goal is to be ok today …and if you are, remind yourself of it.

Arising from your own cells & living amidst them, the emperor of all maladies insidiously grows… gets noticed and then ……..gets ignored. ” Yes I’ve had this lump for 2 years..but it didn’t hurt.” or “She really didn’t say it bothered her..so we never thought it could be serious.” Oncologists hear this day-in and day-out . A countless times we find ourselves saying “Most cancerous lumps don’t hurt” ..yet saying it a bit too late.

The reaction is one of surprise” You’re saying something as serious as cancer doesn’t hurt?”

When your tooth hurts, you see a dentist….If your knee hurts, its hard to walk and you see a joint specialist.

You have a little painless lump ….it doesn’t bother you….you do nothing about it.

” Not causing pain early in the disease” is probably cancer’s best weapon...I wish it did hurt..coz then we’d do something about it sooner.

]]>https://punebreastcare.wordpress.com/2015/03/11/what-oncologists-want-to-scream-and-tell/feed/0drpranjaliScreen shot 2015-03-11 at 10.09.05 PMI’ve Completed Cancer Treatment….But I Don’t Know If I’m Cured.https://punebreastcare.wordpress.com/2015/01/20/ive-completed-cancer-treatment-but-i-dont-know-if-im-cured/
https://punebreastcare.wordpress.com/2015/01/20/ive-completed-cancer-treatment-but-i-dont-know-if-im-cured/#respondTue, 20 Jan 2015 15:44:42 +0000http://punebreastcare.wordpress.com/?p=512Continue reading I’ve Completed Cancer Treatment….But I Don’t Know If I’m Cured.]]>There’s an expected a sense of relief after completion of cancer treatments. You’ve fought and you’ve endured. It’s been a few months of intense physical and emotional exercise. One would hope for a celebration that says, “You did it… you’re cured.” Unfortunately that’s almost never the case. A gnawing question lingers at the back of almost every cancer patients mind, “What if it comes back?” Fear of recurrence is not unfounded…its real.

“Is it really gone?”

“Will it come back some day? and if so.. when?”

“Is this little spot, a sign of the cancer coming back?”

During active treatments there’s a whole bunch of doctors around who you could direct these doubts to. Once treatment is complete however, it can be a touch facing these questions alone. The doctor visits have lessened, friends and family have gone back to work. You’re supposed to be back to normal and you’re not sure you are.

Here are a few thoughts on this fear of recurrence

Understand the “New Normal”: After cancer treatment you don’t go back to feeling how you were before diagnosis. You find a “new normal”. You may have some complaints that will improve over time and some that you will eventually learn to live with. That’s the truth, don’t let anyone ask you to expect otherwise.

Discuss your fears and symptoms: Make a special visit to your oncologist to talk about it. You may find that your risk of recurrence is not as high as you think. A symptom bothering you may be nothing to worry about, or could be something easily treated.

You can only do what you can do: Completing prescribed treatments and keeping regular follow up is something in your hands. What the cancer may do in spite of that is really not in your control. You do what you must do, let your doctors do what they can do and then ‘sit back’ and hope for the best.

Some days are good , others not so much: You may never completely quit your fear of recurrence and that may not be a bad thing. In fact, it may exhort you to keep those follow up appointments and maintain a healthy lifestyle. Every now and then, we all have days that can weigh us down. When you have yours, the “I’ve had cancer” thought will cross your mind. You can acknowledge what you feel, but don’t let it limit your life too much.

Worrying all the time is wasteful: Its true that a certain percentage of patients in your cancer type will have a recurrence. You may fall into that subset or you may not. If you are in the unfortunate group that will recur, you’ve wasted precious years “worrying” that you might have spent “living”. If you’re in the group that’s not going to recur, well then again you’ve wasted time in unnecessary worry.

]]>https://punebreastcare.wordpress.com/2015/01/20/ive-completed-cancer-treatment-but-i-dont-know-if-im-cured/feed/0drpranjaliNewlife“Doctor Shopping”- Second Opinions in Oncologyhttps://punebreastcare.wordpress.com/2014/11/08/doctor-shopping-second-opinions-in-oncology/
https://punebreastcare.wordpress.com/2014/11/08/doctor-shopping-second-opinions-in-oncology/#respondSat, 08 Nov 2014 18:08:59 +0000http://punebreastcare.wordpress.com/?p=506Continue reading “Doctor Shopping”- Second Opinions in Oncology]]>A patient and family facing a diagnosis of cancer, are perhaps going through some of the scariest moments of their lives. They seek an oncologist’s knowledge and experience to help them sail through this rough time. The underlying assumption is that the oncologist will help them understand the disease and will plan a treatment that is in the best interest of the patient. Ideally this could be accomplished in a single visit “the first opinion.” After an initial opinion is sought however, patients and families often seek multiple “second opinions” prior to proceeding with treatment. Several reasons perhaps exist why second opinions are so commonly sought in oncology.

The stakes are high and one wants to make sure no mistakes are made where life and death is concerned.

You don’t have a “family oncologist” The oncologists are specialists you have likely never met before this diagnosis. Unlike with your family doctors, there is no ongoing trust relationship prior to diagnosis.

Second opinions are easily available. You hear multiple people recommending different doctors based on their experiences and even overheard information. Its easy to book multiple appointments with different oncologists even in same day.

The hope is that two oncologists would say the same thing, and reassure the patient of being on the right track. The “doctor shopping” experience however is seldom so easy. The multiplicity of opinions does not always make treatment choices easier. More often perhaps than not, the second opinion will be different from the first.

Some possible reasons why patients may hear different opinions about the very same case from different doctors may be

Oftenthere is really no “ one right answer” ; pros and cons of different approaches need to be weighed into making decisions. Often even best evidence and literature may not prove one approach to be better than another, and the oncologist has to simply pick one. In such cases different options may all still be safe and valid, even though they appear quite different from each other.

Oncologists practice in different eras. The expectation is all oncologists keep themselves updated with present-day best practices. Yet, there’s oncologists you may meet whose training periods may be separated by 30-40 years and some practice differences may be reflective of this time separation. There’s a ‘dogma generation’ and there’s a ‘data generation’ and they both believe they’re right.

Oncology is a business. The fact is oncologists want to keep their business running and want to “bring and keep the patient” under their care. Surgeons make money from operating, oncologists by giving chemotherapy and so on. The expectation is no one wants to give you a certain treatment simply to make money, yet sadly there’s plenty of leeway to conceal dubious intentions.

Just how many opinions a person seeks before he or she is satisfied varies greatly, yet there appear to be different styles and agendas to doctor shopping.

Finding the truth: An educated and well-informed section of patients, will seek to understand diseases and treatments in depth. They will often cross verify the doctor’s opinions with their own reading. They need doctors to satisfy all their queries until they feel ready to proceed.

Finding a fit: A specific gender of a doctor, A well-informed doctor who listens, a greying authoritative figure, may all be different doctor attributes that work for different people. Ultimately they seek opinions till they feel “this is my doctor”

Finding what you want to hear: In opinion shopping, one must learn to recognize this dangerous trait within oneself. It’s a pattern of shopping that may start with oncologists and may end with faith healers. There is always someone somewhere who will tell you just exactly what you want to hear, regardless of how ridiculous and …regardless of how wrong.

Finding someone to steer: Some patients find it very difficult to make choices in what is already a stressful time. They want to give up the driver seat to the treatment planners. After being offered choices by different doctors, they find security in someone who tells them exactly what to.

Finding a bargain: Oncological treatments can be an enormous economic burden. Insurance empanelment and variation of treatment charges between doctors or hospitals can greatly influence decisions. Convenience of location, conveyance and similar logistics may play a role in shopping until a bargain deal appears.

If conclusion, I’d say if you must shop doctors then shop informed, shop to seek the truths, shop till you find your own fit. Be aware of the dangers, don’t be hassled by contradictory opinions and don’t let the process delay treatments. At the end of the day, find someone you can trust..and then dotrust them ..or else the journey can be a lot more tiring than it needs to be.

When you’re diagnosed with cancer, you hear a lot of “Everything’s going to be Just Fine…Don’t worry” The comment is a reflex reaction intentioned to bring hope and comfort to the patient. However it mostly lessens the anxiety of the “comforters” rather than the “comforted”. The cancer patient on the other hand is thinking ” Really..how can I not worry? Do you even get it?”

If the word cancer doesn’t bring worry, there’s something wrong with your head. Every cancer patient will have worries. The immediate worry in hearing the word cancer is “Am I going to die now” Even when the prognosis is good, treatments demand a sizable commitment of time, emotion, energy, money…there’s suddenly a lot to get done. Cancer treatments is probably one of the toughest time in an individuals life. Even after completing treatment for early stage cancer, theres a worry about ” Is it going to be back” In advanced and late stage disease the worry is ” How much longer? Is my family going to be ok?”

So separating “worry” from the word cancer is hard to do and an unreasonable expectation. The goal is to help a person live through this worry, get past it and be there in the journey. Denying that is a worrisome situation , is not going to help. Most people have no idea what the right thing to say is in a clearly wrong situation. If you want help a cancer patient that is worried and afraid

-be there to listen when they want to talk about it

-allow them to cry when they have to

–“I really don’t know what to say” is an acceptable response

-its ok to be real and say “Shit..that sucks”..”but I’m here for you”

Lorry Hope has a written a great book “Help me live” that talks about what to say and what not to say to a cancer patient Strongly recommend it to anyone looking for more advice on the topic.

Social media platforms are a great way to improve health awareness. However most circulating messages and emails, contain information that has not been reviewed by reliable sources. Often search engines direct surfers to blogs and patient forums that are simply personal anecdotes and often misguiding. I caution patients against making any health related decisions based on such information. October is breast cancer awareness month. BeBreast-Aware but also Beware of common myths. Here’s some popular misconceptions about breast cancer.

Myth 1) If A Breast Lump Is Not Painful, Its Not Cancer.

Most breast cancers present as painless lumps in the breast. The lack of pain is common reason women do not find them early and when they do, they do not seek attention with urgency. Breast pain on the other hand especially varying with the menstrual cycle (cyclical mastalgia) is a common problem but almost never a sign of cancer. Any breast lump or swelling should be appropriately investigated, regardless of whether it is painful or not.

Myth 2) Women Who Breast-Feed, Cannot Develop Breast Cancer.

Although breastfeeding decreases risk of breast cancers, the risk is not eliminated. A woman should not assume that because she has breast-fed, she will not develop breast cancer. Few generations ago women had several children and they breast-fed each of them for a 1-2 years. Today women have fewer children and only a small part of the woman’s reproductive years are spent breast-feeding. For an individual woman today, breast feeding should still be strongly encouraged but mainly for the health of the baby.

Myth 3) Fibroadenomas Can Transform To Cancer.

A Fibroadenoma is a benign tumor, not cancerous to any extent. Fibroadenomas do not transform to cancers. They do not increase risk of developing breast cancers. If a needle biopsy has proven with certainty that a growth is benign, it can be observed and does not always need to be surgically removed. However when fibroadenomas grow rapidly, the possibility of a rare tumor called phyllodes may be considered and hence excision may be advised.

Myth 4) A Needle Biopsy Of A Breast Cancer, Causes It To Spread.

A needle biopsy is often advised to complete triple assessment for a breast lump (which includes physical exam, imaging and needle biopsy ) There is no evidence that a needle biopsy would cause spread of the breast tumor. It is a simple OPD procedure done under local anesthesia that can avoid surgery for diagnosis. If a needle biopsy proves a growth to be benign (non-cancerous) unnecessary surgery may be avoided. If a needle biopsy shows cancer, the right treatment plan can be made upfront, avoiding multiple surgeries.

Myth 5 )Black Bras Cause Breast Cancer.

The type of bra, color or fit of the bra, have nothing to do with breast cancer risk. Common theories floating on the Internet are that bras block circulation, this accumulates toxins, black color absorbs radiation etc. I must say they are all very well cleverly contrived theories but all quite baseless. The bra is mostly an innocent bystander to an accident in the area.

Myth 6) Hysterectomy Increases Breast Cancer Risk.

Having a hysterectomy for problems such as fibroids, heavy bleeding etc. does not increase subsequent breast cancer risk. Women who have had ovaries removed before 45 years, should bear in mind that such surgery does not eliminate your breast cancer risk although it may lower it slightly. You still need to undergo regular breast exams.

Myth 7) Mastectomy for Breast Cancer Treatment, Prevents Recurrence.

Women that have an early stage breast cancer may be offered options of undergoing a lumpectomy (removal of the area bearing tumor) and radiation versus undergoing a mastectomy (removing the whole breast). In carefully selected patients, both options are equally safe from a survival standpoint. Women often assume that removing the whole breast would completely prevent the tumor from coming back. This unfortunately is not true. Although treatments are designed to minimize risk, women can still have recurrence sometimes years after surgery, regardless of the type of operation. Breast cancer patients need to keep lifelong regular follow up with their oncologists.

Myth 8) Women Who Have No Family History, Will Not Develop Breast Cancer.

Most breast cancer cases occur in women who have no significant family history of breast ovarian or other cancers. Only 5-10% of breast cancers can be attributed to known genetic defects that are inherited. Women are often surprised that they have breast cancer when no-one in their family has it. If you have a breast lump, but no family history, do not assume that it cannot be a serious problem.

Myth 9) Breast Cancer Can be Prevented by Vaccination

Unlike cancer of the uterine cervix (cervical cancer) which can be largely prevented by vaccination against HPV (Human Papilloma Virus), there is no vaccine currently available anywhere in the world to prevent breast cancer. Vaccines that are often discussed in the press are in research for specialized treatments and not for prevention of breast cancer. Exercise, low fat diet, maintaining normal weight, avoiding tobacco or alcohol and minimizing use of hormone replacement therapy can all help decrease risk of breast cancer.

Myth 10) All Breast Cancer Is The Same

Breast cancer is not one single disease. It is a term that encompasses hundreds of different subtypes at a molecular level each with its own behavior. Breast cancer treatments are now personalized where the treatment is offered based on the specific characteristics of a patient’s tumor. It is hence very likely that the treatment offered to a friend or family member for a breast cancer will not be the same that you need for yours.